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What is the lesion on this elderly man's scalp?

This 82-year-old widower’s carer spotted this oozing lesion and insisted he visit his GP. Dr Mike Wyndham describes how it was diagnosed

 

The patient

This 82-year-old man had lived alone since his wife passed away two years previously. He had no family living locally and was very much dependent on his young carer, finding it very difficult to get around because of his advanced osteoarthritis.

The carer had been watching this lesion on his scalp grow for a year or so and had been assured by him that it had been previously checked by the GP and all was okay. But the last time she washed him, she noticed that it was now oozing and beginning to smell, leading to an ultimatum that she was not going to wash his head unless he saw his GP again.

His medical history listed hypertension, gout and osteoarthritis. He had been a heavy smoker for most of his life and couldn't see any point in giving up when I saw him a couple of years ago.

I visited him at home and noticed that he was wearing a baseball cap but I was somewhat shocked to see the lesion on his scalp. It was about 5cm in diameter and oozing a little. The appearance of the surface, although mostly smooth, had a ‘non-uniform' appearance.

First instinct

I've found it useful to combine two parameters when looking at isolated skin lesions: age and location. For example, an itchy rash of the antecubital fossa of an infant is likely to be atopic eczema unless proved otherwise. Single lesions on the scalp of elderly people are likely to be pre-malignant or malignant.

Differential diagnosis

• Squamous cell carcinoma

• Pilar cyst

• Basal cell carcinoma

• Skin metastasis from a malignancy

Squamous cell carcinoma may start with a nodular appearance before becoming ulcerated and developing a surface crust. This lesion did not really fit with that description.

Pilar cysts are less common than epidermoid cysts and do not have a punctum. When found on the scalp, there may be more than one. Certainly there was only one lesion present here, and they generally develop in patients aged 15-30.

Basal cell carcinomas most commonly develop on the face. Telangiectases may be present on the surface and in this case there were some present. Its edge was curved, as you might expect with cystic basal cells.

I have only ever encountered a metastasis to the scalp on one occasion, and that was caused by lung cancer. It did have an unusual raised appearance and didn't really conform to the description of any of the lesions that one normally encounters on the scalp. Was this a possibility in view of the smoking history?

Getting on the right track

Ultimately, there was only going to be one way to make the diagnosis for this lesion and that was a biopsy. Slightly surprisingly, it turned out to be a squamous cell carcinoma, which was excised and grafted.

Dr Mike Wyndham is a GP in Edgware, north London

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